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Ann Thorac Surg 2001;72:1711-1715
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Current strategy for surgical management of bronchiectasis

^a Department of Thoracic Surgery and Endoscopy, Ruhrlandklinik, Essen-Heidhausen, Germany

Accepted for publication June 28, 2001.

* Address reprint requests to Dr Fujimoto, Department of Thoracic Surgery and Endoscopy, Ruhrlandklinik, Tüschener Weg 40 45239 Essen, Germany
e-mail: fjmtt{at}aol.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. There are few current reports of surgical management for bronchiectasis because of its decline in prevalence, and it remains controversial as to which subgroups of patients would benefit from surgical management.

Methods. We reviewed the medical records of all patients who underwent surgical resection for bronchiectasis between January 1, 1990, and December 31, 1997, at our hospital.

Results. Ninety patients underwent 92 operations for bronchiectasis. The mean age was 44.7 years. The presenting symptoms were productive cough in 82 patients, fever in 47 patients, hemoptysis in 35 patients, chest pain in 6 patients, and dyspnea on effort in 4 patients. The disease was bilateral in 13 patients. Complete resection was achieved in 75 patients. There was no operative mortality, and the morbidity rate was 19.6%. Postoperatively the patients were asymptomatic in 45.6%, improved in 38.0%, and showed no improvement in 16.4%. Logistic regression extracted the type of bronchiectasis, the existence of sinusitis, and the type of resection for prognostic discrimination with statistical significance.

Conclusions. Surgery for bronchiectasis can be performed with acceptable morbidity and mortality. Patients with cylindrical bronchiectasis are good surgical candidates and chronic sinusitis is a risk factor for surgical resection. Complete resection should be done whenever possible.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Bronchiectasis, first described by Laennec [1] as the pathologic changes of abnormal bronchial dilatation with chronic necrotizing infection, now generally refers to the clinical syndrome caused by abnormal dilatation of bronchi. The clinical features of the disease may vary widely, from a chronic cough to a massive hemoptysis in need of urgent care. In this era of current antibiotic therapy, the prevalence of the disease in industrialized countries has declined significantly and consequently few recent reports of surgical management are available. Some reports showed that a limited localized disease was associated with good postoperative prognosis [2, 3], but other factors affecting prognosis after operation still remain controversial.

The purpose of this study is to present the early and long-term results of our 8-year surgical experiences to reevaluate our decision for using surgical therapy, and to analyze several factors that might affect the prognosis of this disease.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
We reviewed 90 patients (18.3%) from 492 patients hospitalized with the diagnosis of bronchiectasis who received operations at the Ruhrlandklinik (Essen-Heidhausen, Germany) between January 1, 1990, and December 31, 1997. These 90 patients underwent 92 operations. Variables of age, sex, symptom, type of bronchiectasis, type of operation, operative morbidity and mortality were analyzed for these 90 patients.

Surgical treatment was considered if the symptoms persisted in spite of several courses of treatments and if the extent would make operations practical. Nonsurgical treatments included appropriate antibiotic therapy, postural drainage with vibratory massage, and also possibly bronchodilator and corticosteroid treatments. The persisting symptoms justifying operations were recurrent pneumonia that requires hospitalization, significant volume of hemoptysis, lung abscess, or empyema. The extent of diseased lung to justify operations must be localized to achieve complete resection as a rule.

Before 1995, preoperative bronchography or chest computed tomography was performed, or both were performed, to evaluate the severity and distribution of bronchiectasis. Since 1995, high-resolution computed tomography has supplanted bronchography in the diagnosis of bronchiectasis. Sputum was cultured for bacterial examination before operation. A respiration-perfusion scintigraphy was done to estimate the postoperative lung function and indeed appropriate cardiorespiratory reserve was necessary for operative consideration. Patients were screened by performing a flexible bronchoscopy to exclude causes such as a central obstruction or stenosis of bronchus caused by tumor, a foreign body, and other causes. As a result, the bronchial obstruction was discovered in 14 patients, and the dilatation of the bronchi was regarded as secondary in these patients (secondary bronchiectasis). These 14 patients were excluded from the study. The causes of the obstructions were old tuberculosis in 9 patients, foreign body in 3 patients, aspergilloma in 1 patient, and bronchial lipoma in 1 patient.

The operative indication for bronchiectasis with hemoptysis was divided into two groups: (1) massive hemoptysis and (2) recurrent episode of significant hemoptysis. Massive hemoptysis was defined as an expectoration of more than 600 mL of blood within 24 hours. For massive hemoptysis, a rigid bronchoscopy was immediately performed under general anesthesia to localize the bleeding site definitely. A tamponade of the bleeding bronchus was performed with a bronchus-blocking catheterization followed by immediate evaluation of the underlying disease for potential operation. This technique and device was reported previously [4]. Patients with bilateral disease were not primary candidates for surgical treatment and bronchial artery embolization was the alternative treatment. Patients with not massive but a significant amount of hemoptysis could be candidates for the surgical treatment if the episode was recurrent and if the patient had an adequate lung function and if the diseased lung were localized. For this type of hemoptysis, a flexible bronchoscopy was enough to recognize the bleeding site. Complete resection also should be accomplished for this indication whenever possible.

For patients with concomitant lung abscess, antibiotic administration was the main treatment, and ideally, surgical management should be delayed until adequate control could be achieved. The abscess was not drained preoperatively. If there were signs, such as increase in abscess size, unremitting sepsis, or contralateral contamination, despite medical treatment, immediate surgical therapy was considered.

Operative technique
A left-sided double-lumen endotracheal tube was used in order to avoid contralateral contamination of secretions. Anterolateral muscle-sparing thoracotomy was used for all patients. Complete resection is defined as an anatomic resection of all affected segments that were assessed preoperatively by either computed tomography or bronchography. This was performed whenever possible while trying to preserve the lung parenchyma as much as possible. The bronchial stump was manually sutured using absorbable materials in all patients and a stump covering with pericardial fat was performed in patients with severe preoperative infection such as empyema.

Clinical findings
There were 44 male and 46 female surgical patients with an average age of 44.7 years and a range of 9 to 75 years. The presenting symptoms were productive cough with recurrent infection (1 to 4 times per year) in 82 patients (91.1%), fever in 47 patients (52.2%), hemoptysis in 35 patients (38.9%), chest pain in 6 patients (6.7%), and dyspnea on effort in 4 patients (4.4%). The mean duration of the symptoms was 10.6 years (range, 0 to 50 years). Concomitant disease was bronchial asthma in 6 patients (6.7%), sinusitis in 11 patients (12.2%), and systemic amyloidosis in 2 patients (2.2%).

The diagnosis was confirmed by bronchography in 42 patients (46.7%), computed tomography in 40 patients (44.4%), and first diagnosed by postoperative pathology in 8 patients (8.9%). Seventy-eight patients (86.7%) received prior medical therapy.

The disease was bilateral in 13 patients (14.4%). The mean number of segments involved was 4.3 (range, 1 to 14 segments). The type of bronchiectasis was cylindrical in 33 patients (35.9%), saccular in 52 patients (56.5%), and varicose in 7 patients (7.6%).

Bacteria was preoperatively proven in 52 patients (57.8%); Haemophilus influenzae in 18 patients, Staphylococcus aureus in 13 patients, Streptococcus pneumoniae in 12 patients, Pseudomonas aeruginosa in 10 patients, Bacteroides and other anaerobes in 6 patients, and Klebsiella pneumoniae in 3 patients.

The indications for pulmonary resection were chronic cough and sputum with recurrent infection in 56 patients (62.2%), hemoptysis in 21 patients (23.3%) including 4 massive hemoptysis, lung abscess in 9 patients (10.0%), undiagnosed lung mass in 3 patients (3.3%), and empyema in 1 patient (1.1%). Fifty patients (54.3%) underwent a lobectomy, 31 patients (33.7%) underwent a segment resection, 6 patients (6.5%) underwent a pneumonectomy including 4 completion pneumonectomies, and 5 patients (5.4%) underwent a bilobectomy. Right thoracotomies were performed on 38 patients, whereas left thoracotomies were performed on 54 patients. Eight of 92 patients (8.7%) had undergone prior operations for bronchiectasis (ipsilateral in 6 patients, contralateral in 2 patients). In 2 of these patients, the first operations were performed in our hospital.

Statistical analysis
The subjective long-term results were obtained by directly asking patients their current status and were classified as "excellent," which meant no postoperative symptoms; "improved," which meant that symptoms remained but better control could be achieved without hospitalization; and "no change." Prognoses of the patients who were not alive at the time of this surveillance (n = 5) were assessed by asking their primary doctors about their last visit status. Prognoses of those patients who had a second reoperation for the disease (n = 8) were evaluated only by the last operation.

Clinical data are reported as a mean value (range). The unpaired Student’s t test and ² test were used for group comparison when appropriate. The influences of some variables upon the prognosis after the operation were studied by dividing the patients into group A (patients with "excellent + improved") and group B (patients with "no change"). Multivariate logistic regression analyses were used to compare a variety of clinical factors between groups. All tests were two-tailed and performed by Statview version 5.0 statistical software (SAS Institute Inc, Cary, NC).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was no operative mortality within 30 days. The mean intraoperative blood loss was 545.1 mL (range, 10 to 1,700 mL), and the mean operative time was 135.3 minutes (range, 65 to 250 minutes). The mean blood loss of ipsilateral secondary operation (n = 6) was significantly more than that of the first operation (1,040.0 mL vs 512.1 mL; p < 0.0001). Pleural adhesion was encountered in 72 patients (80.0%). Complete resection was achieved in 75 patients (81.5%). Thoracic drain was extubated in 1 to 95 days after operation with average days of 10.3. The mean duration of hospital stay was 20.3 days (range, 10 to 104 days).

Complications had occurred in 17 patients (19.6%). These complications included sputum retention, which needed bronchoscopic aspiration in 5 patients; postoperative air leak more than 2 weeks in 5 patients; empyema in 4 patients; pneumonia in 3 patients; bronchopleural fistula in 2 patients; atelectasis of the lower apical segment in 1 patient; postoperative bleeding that needed revision of the thorax in 1 patient; and respiratory insufficiency that required mechanical ventilation in 1 patient.

Recurrence of bronchiectasis was encountered in 4 patients (4.4%); 2 patients after lower lobectomy, one after middle lobectomy, and one after basal segmentectomy. Two of these patients had contralateral restricted bronchiectasis, which was not seen in the first operation, and therefore each underwent a second operation. The other 2 patients were not considered as an indication for a second operation because bilateral diffuse bronchiectasis developed after the first operation. One of them also had systemic amyloidosis.

Questionnaires were answered for 79 patients (87.8%). The mean follow-up of these patients was 6.1 years (range, 0.6 to 10.8 years). Thirty-six patients (45.6%) were asymptomatic after operation and 30 patients (38.0%) had improved, whereas 13 patients (16.4%) had no improvement. The overall results of surgical therapy over the last 30 years including our series are summarized in Table 1 [2, 3, 5–10]. The results of multivariate logistic regression analyses according to the different variables are listed in Table 2. The analyses extracted the type of bronchiectasis (p = 0.0489), the history of sinusitis (p = 0.0014), and the type of resection (p = 0.0003) for discrimination between groups A and B.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Most of the morphologic changes of bronchiectasis are heterogeneous and differ by locations. Because postoperative deterioration of even slightly altered bronchi often occurs [8], complete resection of the diseased lung must always be tried, even though the part of the lung seems less diseased, provided that the patient’s condition allows an operation and at least 6 normal segments can be preserved [12].

High-resolution computed tomography is currently a modality of choice in the diagnosis of bronchiectasis with only a 2% false negative and a 1% false positive rate [13]. The two main findings in the diagnosis of bronchiectasis are that (1) the internal diameter of the bronchus is more than 1.5 times greater than that of the accompanying pulmonary artery, and (2) there is evidence of lack of tapering of the bronchus [14].

Preoperative bronchoscopy should be routinely done to rule out benign or malignant causes of obstruction [3]. Generally, particular causes of obstruction tend to be located at particular sites, such as an epithelial tumor at the upper lobe, tuberculous lymphadenitis at the hilum causing collapse in the middle and lower lobe, and a foreign body confined to the right lower lobe [15]. We operated on 14 patients with secondary bronchiectasis caused by central obstruction or stenosis in the same period as that of this series. Lobectomy was the primary treatment of choice, which was different from that for primary bronchiectasis.

Massive hemoptysis is a life-threatening condition that is defined as an expectoration of 200 to 1,000 mL blood within 24 hours [16]. Emergency operations should be reserved for those patients who continue to have massive bleeding despite conservative therapy, because it is associated with a high mortality rate [17]. A balloon blockade of the bleeding bronchus is an effective method in the emergency management, and it can buy time to evaluate the underlying disease and to make the planning of a precise resection of the diseased lung possible [4]. Bronchial artery embolization is a good alternative, which results in an immediate termination of bleeding in 75% to 90%. However, the preoperative assessment after initial cessation of bleeding should be done quickly because recurrence is frequent during the first month after bronchial artery embolization and would be lethal [18]. In our series we experienced 4 patients with massive hemoptysis. Initial stabilization of the bleeding could be achieved in all of them by these techniques and subsequent operations could be performed safely.

We agree with the current tendency of preserving the apical segment of lower lobe (S6), although the morbidity would be higher [19, 20]. It is finally a surgeon’s decision whether to preserve the segment by assuming postoperative prognosis of preserved S6. In our series, 12 patients underwent lower lobectomy, although altered bronchi in S6 were not recognized preoperatively. The reason for not preserving S6 was hypoplasia of inferior pulmonary veins in 6 patients, small parenchyma in 4 patients, and existence of postinflammatory induration in S6 in 2 patients. As a result, atelectasis of the preserved S6 occurred only in 1 of 16 patients (6.3%) who underwent basal segmentectomy, and it could be treated conservatively.

Because of chronic inflammation, pleural adhesion is commonly encountered during operation. Bleeding volume would be more than expected and adequate preparation should be taken especially by the ipsilateral second operation, such as completion pneumonectomy, because pleural adhesion would be so severe that extrapleural dissection and intrapericardial vessel ligation might be necessary.

Completion pneumonectomy is reported to be a high-risk procedure especially when done for a benign disease [21]. We have reported that the procedure could be performed with acceptable mortality and morbidity even for a benign disease with the exception of an operation done for an early complication of an initial operation, such as bronchopleural fistula, bleeding, and so forth [22]. We performed four completion pneumonectomies in this series. There was no mortality and 1 patient had postoperative bronchopleural fistula that could be managed conservatively.

Complication occurrence is 9.4% to 24.6% in the current literature and therefore our result of 19.6% is acceptable (Table 1). Bronchopleural fistula occurs in 0 to 9.1% in this infectious indication. In our series, it occurred in 2 patients (2.2%); in 1 patient it was after completion of pneumonectomy for exacerbation of bronchiectasis, and another patient had preoperative severe pneumonia that could not be completely absolved before the operation. Indeed, operation should be delayed in case of severe inflammation until adequate control has been achieved. If adequate control is impossible, covering of bronchial stump should be considered. To avoid empyema, we recommend postoperative bacterial culture of thoracic effusion if the remaining lung shows signs of persisting inflammation. Sputum retention is common because patients with this disease might have problems with ciliary motion and postoperative expectoration, which would be easily disrupted. We should not hesitate to use bronchoscopy for sputum aspiration in early postoperative days if physiotherapy is not effective.

Ripe [2] described several prognostic factors that predicted good operative results, such as a history of pneumonia, none or minor airway obstruction, absence of sinusitis-rhinitis, low age at the time of operation, and restricted unilateral bronchiectasis in the basal segments of the lower lobes. In addition, preoperative infection by Pseudomonas aeruginosa was chosen as a variable for prognostic analysis in our series because the bacterium may be related to the development of new bronchiectasis [23]. However, logistic regression extracted only three variables as significant prognostic factors: (1) cylindrical type of bronchiectasis, (2) absence of sinusitis, and (3) complete resection of the diseased parenchyma.

In conclusion, surgical resection for bronchiectasis can be performed with acceptable morbidity and mortality when done with a definite strategy and strict criteria. Patients with cylindrical type of bronchiectasis are good candidates for surgical resection. We should select patients carefully if they have concomitant chronic sinusitis because it affects the prognosis adversely. Complete resection should be performed whenever possible.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ludger Hillejan Georgios Stamatis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fujimoto, T. Articles by Stamatis, G. Search for Related Content PubMed PubMed Citation Articles by Fujimoto, T. Articles by Stamatis, G. Related Collections Lung - other